This is an application for a K08 award for Sunitha Kaiser, MD MSc, a pediatric hospitalist at the University of California, San Francisco. Dr. Kaiser is establishing herself as a young investigator in accelerating use of evidence-based guidelines in clinical practice to improve quality of hospital care for children, an AHRQ priority population. This award will provide Dr. Kaiser with the support necessary to accomplish the following goals: (1) to become expert in qualitative research methods and implementation science; (2) to gain experience in conducting a trial; (3) to gather preliminary data for the purpose of designing a multi-site trial; and (4) to develop an independent clinical research career. To achieve these goals, Dr. Kaiser has assembled a multi- disciplinary mentoring committee whose expertise spans the relevant disciplines of asthma and clinical trials (Drs. Cabana, McCulloch and Horwitz), health services research (Drs. Auerbach, Cabana, McCulloch, and Horwitz), qualitative research (Dr. Rehm), and implementation science (Drs. Auerbach, Cabana, and Horwitz). Asthma is the second most common cause of pediatric hospitalizations1 in the United States, resulting in nearly $1 billion in annual costs. Despite broad dissemination of evidence-based guidelines for asthma management, there are significant variations in care and risk-adjusted outcomes for children hospitalized with asthma, largely due to challenges integrating guidelines into care. Clinical pathways are structured, multidisciplinary, and detailed care plans for patients with a specific clinical problem; they link evidence to practice to optimize patient outcomes and delivery efficiency. In controlled trials, pathways reduce inappropriate variation in care and improve outcomes for children hospitalized with asthma by both increasing home asthma management education and decreasing hospital length of stay. However, there is wide variability in performance and uptake of pediatric asthma pathways in real-world settings due to a dearth of evidence- based guidance on successful implementation methods. Dr. Kaiser's long-term goal is to become an independent investigator who leads efforts to improve quality of care for hospitalized children by accelerating use of evidence-based guidelines in clinical practice. Dr. Kaiser's objective is to identify, test, and disseminate best practices for pathway implementation to improve quality of care for children hospitalized with asthma. The central hypothesis, derived from the positive deviance approach, is that identification and examination of hospitals that demonstrate exceptional performance with pathway implementation can facilitate the discovery and wide dissemination of strategies to improve care. Steps in this mixed-methods approach include: 1) identify hospitals where pathway implementation led to the largest gains in performance, 2) study these hospitals using qualitative methods to identify best practices associated with high performance, and 3) test these best practices with rigorous design. The rationale is that high-performing hospitals will have replicable pathway implementation practices that will be critical to widespread national uptake, ultimately leading to consistent delivery of evidence-based practices and higher quality of care. This hypothesis will be tested by pursuing three specific aims: Aim 1) Identify hospitals where implementation of inpatient pediatric asthma pathways has led to the largest improvements in quality of care. Key personnel from 43 children's hospitals that contribute to a national administrative database will be surveyed to determine if and when asthma pathways were implemented, then the database will be used to identify which hospitals had the greatest gains in quality of care with pathway implementation. Aim 2) Determine best practices for implementation of inpatient pediatric asthma pathways through in-depth qualitative analysis of key personnel from the high-performing hospitals identified in Aim 1. Aim 3) Conduct a pilot trial to determine the feasibilityof implementing inpatient pediatric asthma pathways utilizing best practices in both a tertiary and community hospital setting. This pilot trial will enroll 50 total children hospitalized with asthma The proposed research is innovative to pediatric clinical pathway research both by shifting the traditional approach to focus on implementation strategies and by utilizing a novel mixed-methodology, based on the concept of positive deviance. The proposed research is significant because it is expected to vertically advance and expand knowledge on best practices for pathway implementation, which will enable increased uptake and successful implementation of clinical pathways in both tertiary and community settings, thereby improving evidence-based practices and quality of care for children with asthma. Ultimately, this new knowledge could support pathway implementation across a range of pediatric illnesses to improve quality of care and decrease unnecessary costs.